Scalable psychological

interventions for people

in communities affected
by adversity
A new area of mental health
and psychosocial work at WHO
Which communities are affected
by adversity?
Communities affected by adversity exist in all corners of the world. In these
communities, most people have experienced severe losses, traumatic events or
other extreme stressors and have limited access to essential resources.

In some cases, the community’s experience of adversity is a single event, e.g. a

natural disaster, an industrial accident, or an act of terrorism. However, in most
situations adversity is sustained, e.g. chronic poverty, endemic community and
gender-based violence, long-term civil conflict or displacement. As a result, new
generations are often born into difficult circumstances involving prolonged
adversity. Although each community is different and will have helpful resources,
most people in such communities do not have access to effective mental health
and psychosocial support.

WHO / Anna Kari

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What is the impact of adversity?
The impact of adversity on a person’s life can be far reaching. It can affect
people’s long-term quality of life and functioning and can significantly
increase an individual’s chance of developing disabling distress. For example,
it is estimated that after a humanitarian emergency, rates of severe mental
disorders increase from 2-3% to 3-4%. Additionally, mild to moderate mental
disorders are estimated to increase from 10% to as much as 15-20% in the
same population.

Although these estimates show how significantly adversity can influence rates
of mental disorders, they do not capture the large numbers of other people
who experience general psychological suffering after adversity. In light of this
reality, it is evident that developing accessible mental health and psychosocial
interventions for populations affected by adversity is a priority.

Irin News / Kate Holt

3
What interventions are potentially
scalable?

Psychological interventions that are potentially scalable include modified, evidence-

based psychological treatments, such as:
• Brief, basic, non-specialist-delivered versions of existing evidence-based
psychological treatments (e.g., basic versions of cognitive-behavioural therapy,
interpersonal therapy).
• Self-help materials drawing from evidence-based psychological treatment
principles, in the form of:
- Self-help books
- Self-help audiovisual materials
- Online self-help interventions.
• Guided self-help in the form of individual or group programs, providing people
with guidance in using the above mentioned self-help materials.

Scalability is not an all-or-nothing concept. Some interventions have features

that make them more scalable than others. Interventions become more scalable
when they rely less on specialist human resources.

To make interventions potentially scalable, aspects about the intervention are

changed so they become feasible in communities that do not have adequate
access to specialists. Such modifications can create more accessible care that
reaches a larger number of people. These modifications could include using
non-specialists to deliver the intervention, or innovative delivery strategies such
as self-help books or using mobile devices.

Some of these interventions, implemented at scale, may prove to be somewhat

less effective than conventional models of psychological treatment. This,
however, may be acceptable in exchange for the increased coverage and
accessibility gained in return. This compromise can be assessed using cost-
effectiveness research methods from the field of health economics.

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Why use scalable interventions?
Global access to care for people with mental health and psychosocial problems
could be significantly improved by developing, implementing, and evaluating
scalable interventions. As highlighted within WHO’s mental health Gap
Action Program (mhGAP), there is a large gap between prevalence of mental
health problems and evidence-based service availability and use in the vast
majority of communities of the world. Therefore, in communities affected by
adversity, where this gap is often even more pronounced, the case for scalable
psychological interventions is especially strong.

Communities facing adversity also tend to have the least developed mental
health care systems and the greatest number of barriers preventing people from
accessing available services. Potential barriers to care include under-resourced
health and social services, limited availability of professionals and poverty.

In recent years, a range of scalable interventions have been found to be

effective for people suffering disabling stress, depression and anxiety. Although
most of this work has been done in high-income countries, our work in this
area will add to substantial path-breaking research over last 15 years by
prominent academics in low- and middle-income countries.

UNHCR / R. Gangale

5
What is our strategy to develop
these interventions?
Informed by WHO’s evidence-based mhGAP guidelines, WHO began designing
and rigorously testing scalable psychological interventions in 2012. The objective
is to develop scalable interventions for multiple age groups across various delivery
models to reach diverse populations.

As part of the mhGAP program, WHO formally reviewed available evidence

and convened expert Guideline Development Groups (GDGs) to advise on
psychological interventions for depression, post-traumatic stress disorder,
medically unexplained somatic complaints, suicide and sub-threshold depression
and anxiety, among other conditions. On the basis of this process, WHO now
recommends a range of psychological interventions, including cognitive-
behavioural therapy, interpersonal therapy and stress management.

Since finalizing the guidelines, WHO has been moving forward in developing and
researching scalable intervention models. For example, with strong support from
academic partners, WHO has developed and published Problem Management
Plus (PM+). PM+ is a brief, individual, multi-component behavioural intervention
which can be delivered by specialists or non-specialists for adults in communities
affected by adversity. It is designed to address psychological and social problems
through problem-solving counselling plus behavioral interventions. PM+ for
individuals has been formally tested in violence-affected communities in Kenya
and Pakistan and was shown to be effective in reducing depression and anxiety
and improving functioning. WHO is currently testing a group version (Group PM+)
in Pakistan and Nepal. Also, WHO has meanwhile published Thinking Healthy,
involving cognitive-behavioural therapy for perinatal depression, and Group
Interpersonal Therapy (IPT) for Depression, which can be delivered by
non-specialists.

WHO is currently devising a range of scalable interventions for adversity-affected

populations based on existing empirically supported treatment approaches, which
currently includes:
• Self-Help Plus (SH+). A multi-media stress management self-help package
involving a pre-recorded audio course supplemented with a self-help book.
• Step-by-Step. Online (e-mental health) intervention based on behavioural
activation with or without minimal support from a non-specialist worker.
• Helping Young Adolescents Cope. PM+ adapted for groups of young
adolescents impaired by distress.

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What are the next steps?
Before WHO will release scalable intervention manuals and materials as global
public goods, it intends to prove the effectiveness of each of the interventions
with two high quality randomized controlled trials (RCTs). RCTs are currently
underway on some of the unpublished interventions, but more will be needed
in order to fulfill this requirement and produce high quality evidence.

WHO is also looking ahead to the post-testing phase, where it seeks to

gain further understanding and develop guidance on how publicly available
interventions can be scaled up as part of existing health, social care, education
or other public service systems.

Implementation perspectives gained from real-world use of scalable

interventions will be shared to contribute to the overall goal of increasing
coverage of evidence based psychological interventions. WHO will be available
to work with key agencies in use of these new tools. Based on such experience,
WHO seeks to develop and evaluate a Guide on Integrating Psychological Care
in Health, Social and Educational Services.

WHO / M. Kokic

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 Graphic design: Alessandro Mannocchi, Rome
What would its impact be on people
affected by adversity?
In moving away from expert-delivered interventions towards self-guided
or non-specialist facilitated interventions, survivors of adverse experiences
and people living in protracted situations of adversity will be able to gain
access to currently unavailable support. By developing, implementing and
evaluating scalable interventions, entire populations gain the potential for
increased capacity for self-help, improved mental health, resilience and
better overall functioning.

What is WHO looking for?

WHO is seeking to promote the agenda of developing, testing, disseminating
and implementing potentially scalable interventions. In addition to securing
partnerships and resources to test the effectiveness of WHO interventions,
WHO also seeks to acquire and disseminate knowledge on implementation
strategies and scale up of such interventions into existing public services
and systems.

The products of this work should contribute to reaching the highest level
of mental health, well-being and overall functioning for all people affected
by adversity.

For further questions, please contact:

Dr Shekhar Saxena: saxenas@who.int

Dr Mark van Ommeren: vanommerenm@who.int

Department of Mental Health and Substance Abuse

World Health Organization, Geneva

WHO/MSD/MER/17.1
© WHO 2017. Some rights reserved.
This work is available under the CC BY-NC-SA 3.0 IGO licence.